| Certificate Number | 579 | | Date Issued |
| Child Given Name | Charles |
Phay | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 07 Mar 1883 |
Zearing Story Co IA | Place of Birth |
| Father's Given Name | Geo R. |
Phay | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Minnesota | 20 | Father's Age |
| Mother's Given Name | Laura | Williams | Mother's Maiden Name |
| Mother's Surname | Phay | Zearing Story Co IA | Mother's Residence |
| Mother's Nationality | American | Pennsylvania | Mother's Birth Place |
| Mother's Age | 20 | 2 | Number of Child This Mother |
| Medical Attendant's Name | A.M. Williams | Zearing IA | Medical Attendant's Address |
| Certificate Signer's Name | A.M. Williams | Zearing IA | Certificate Signer's Address |
| Returned by Name | A.M. Brooks | | |